It is a patchwork of cockamamie carrots and sticks, agencies and incentives, exceptions and accounting tricks, cajoles and punishments, cobbled together over some 50-100 years of legislation that itself was a product of pressure-group pushes, graft, loopholes, mandates, and subsidies. 

It's not even a clean public-private partnership. It's a public-private-nonprofit-grifter-payola regulatory cacophony of confusion and chaos over which pharmaceutical companies and professional lobbyists exercise the dominant influence. 

Still it quasi-functions. It hobbles along year after year with ever more expense and administrators, with ever worse results. Absolutely no one would design such a thing from the ground up. No one is particularly happy with it but neither is there much push to change it fundamentally. 

The Covid years devastated trust or, perhaps, just pulled back the veil. Every poll confirms it, e.g. a Harvard/Northwestern poll showed that trust fell from 71.5% in April 2020 to 40.1% by January 2024 across all groups. The reality is likely far worse. Everyone is asking how to restore trust. 

The last time centralized reform was attempted was 15 years ago. The debates about Obamacare minted a healthcare expert daily and generated think-tank blueprints reflecting every ideological bias. The final product of a thousand pages, in which no one group got its way, was shoved through with great huzzahs on one side and boos on the other. It resulted in more coverage, yes, but also cost increases anywhere between 50 and 500 percent depending on how one chooses to measure it.

No one can produce evidence that it has made America more healthy. A statistical tour through chronic disease data, or a casual walk through a mall or airport, proves that. 

The debate over the Affordable Care Act pretty well exhausted the appetite for far-reaching reform. And maybe that is a good thing because the drive today is not for one system for everyone but a realization that the needs are so diverse and diffuse that it would likely have more success with a series of parallel systems that emerge from the ground up. 

Thus has most of the Make America Healthy Again (MAHA) agenda focused on matters that individuals and families can do themselves. They include being more scrupulous about diet, exercise, sleep, sunshine, and caution about prescription medications, whether for mental or physical maladies. The movement against mandates is at the core simply because it now (versus a few years ago) pertains to children and relates directly to the grave concern about ill-health and the rise of autism. 

Again, this is a more productive conversation than going back to the drawing board to reform a system that has no name and hardly anyone understands in its totality. It recognizes something crucial, namely that health is not granted by a system of government or a large insurer but rather emerges from individual decisions and habits. In large part and with the exception of unpredictable twists of fate, much of what we call health is mainly within our own control.